Papers by George Alexopoulos
Handbook of Behavioral and Cognitive Therapies with Older Adults, 2008
... skills, which amplifies the experience of adversity; poverty level older adults often experie... more ... skills, which amplifies the experience of adversity; poverty level older adults often experience difficulties in negotiating obstacles and ... Stigma and loss of face about mental illness contribute to reluctance among ethnic minorities to utilize mental health ... CB Case Management 231 ...
The American Journal of Geriatric Psychiatry, 2015
Both executive dysfunction (ED), measured by performance-based tasks, and dysexecutive behavior (... more Both executive dysfunction (ED), measured by performance-based tasks, and dysexecutive behavior (DB), measured by behavioral rating scales, contribute to late-life depression and comorbid disability. There is a modest positive association of ED and DB, but less is known about their relative contributions to core aspects of neuropsychiatric conditions and whether they provide unique or redundant information. Latent variable analyses were applied to ED, DB, depression, and disability data from 220 older patients with major depression and ED who had been enrolled in a psychosocial treatment study of depression. ED measures included the Trail Making Test, part B, Stroop Color Word Interference Test, and Hopkins Verbal Learning Test-Trail 1. The ED scale from the Frontal Systems Behavior Scale, self and other-rated, served as the ratings-based measure of DB. The measurement model, with all four latent variables related to one another, demonstrated good fit (RMSEA = 0.06). In the structural models, DB was associated with both depression (β = 0.61) and disability (β = 0.42), whereas ED was associated with depression (β = 0.43) but not disability (β = 0.16). Social problem-solving accounted for 49% of the influence of DB on late-life depression, whereas ED was not related to social problem-solving. ED and the lesser studied DB measures offer unique and complementary information. DB was robustly associated with late-life depression and disability. Patients with depression and ED may be more likely to develop disability when they exhibit DB and social problem-solving difficulties.
Journal of Psychiatric Practice
Agitation frequently accompanies dementia, causing severe stress for caregivers and often leading... more Agitation frequently accompanies dementia, causing severe stress for caregivers and often leading to institutionalization. There are limited controlled data concerning the best methods of treating this agitation, which led the authors to undertake a survey of experts in the field on unanswered clinical questions. The survey results of which were published in 1998 as the Expert Consensus Guidelines on the Treatment of Agitation in Older Persons with Dementia. In this article, the authors summarize the clinical recommendations given in these guidelines. They discuss the differential diagnosis of agitation in dementia and the variety of problems that can cause agitation in these patients (medical conditions, physical discomfort, environmental stresses, and neuropsychiatric syndromes such as psychosis, anxiety, depression, insomnia, or sundowning). Principles to guide treatment planning and the essential components in a medical evaluation of agitated patients with dementia are then revi...
The American Journal of Geriatric Psychiatry, 1999
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 2007
Much of the response to an antidepressant is the result of placebo response. The placebo response... more Much of the response to an antidepressant is the result of placebo response. The placebo response embedded in drug response confounds studies seeking to identify brain mechanisms essential for pharmacologic response. Exclusion of patients who fail to meet entry criteria at the end of a placebo lead-in phase has been inadequate to reduce the effect of placebo during pharmacologic trials. This study focused on the placebo lead-in phase and examines whether change in severity of depression during placebo lead-in predicts change in depressive symptoms during antidepressant treatment. The subjects were patients aged 60-85 years with nonpsychotic unipolar major depression not attributed to dementing disorders, medical illnesses, or drugs causing depression and had a 24-item Hamilton Depression Rating Scale score of 18 or greater. After a two-week placebo lead-in, subjects with Hamilton Depression Rating Scale score of 18 or greater received 10 mg escitalopram for 12 weeks. Worsening or li...
Current treatment options in psychiatry, 2014
We systematically reviewed randomized clinical trials of problem-solving therapy (PST) in older a... more We systematically reviewed randomized clinical trials of problem-solving therapy (PST) in older adults. Our results indicate that PST led to greater reduction in depressive symptoms of late-life major depression than supportive therapy (ST) and reminiscence therapy. PST resulted in reductions in depression comparable with those of paroxetine and placebo in patients with minor depression and dysthymia, although paroxetine led to greater reductions than placebo. In home health care, PST was more effective than usual care in reducing symptoms of depression in undiagnosed patients. PST reduced disability more than ST in patients with major depression and executive dysfunction. Preliminary data suggest that a home-delivered adaptation of PST that includes environmental adaptations and caregiver involvement is efficacious in reducing disability in depressed patients with advanced cognitive impairment or early dementia. In patients with macular degeneration, PST led to improvement in visio...
Current psychiatry reports, 2014
Suicide in older adults is a significant clinical concern. In this review of recent findings, we ... more Suicide in older adults is a significant clinical concern. In this review of recent findings, we concentrate on the role of emotions and cognition in suicide risk and behavior in older adults. We discuss the epidemiology of suicide in older adults, integrate recent findings on non-psychotic major depression, schizophrenia and suicidal ideation, explore the relationship of emotion regulation with suicide, present recent advances on suicide in demented patients, and describe the latest developments on cognition and decision processes in suicide.
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 1994
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 2010
This preliminary study examines the efficacy of 12-week home-delivered problem adaptation therapy... more This preliminary study examines the efficacy of 12-week home-delivered problem adaptation therapy (PATH) versus home-delivered supportive therapy (ST) in reducing depression and disability in 30 depressed, cognitively impaired, disabled older adults. A 12-week randomized clinical trial. Research assistants were unaware of the participants' randomization status. Assessments were conducted at baseline, 6 weeks, and 12 weeks. Weill-Cornell Advanced Center for Interventions and Services Research. Thirty elders with major depression, cognitive impairment, and disability were recruited through advertisement and the Home-Delivered Meals Program of the Westchester County Department of Senior Programs and Services. PATH is a home-delivered intervention designed to reduce depression and disability in depressed, cognitively impaired, disabled elders. PATH is based on problem-solving therapy and integrates environmental adaptation and caregiver participation. PATH is consistent with Lawton&...
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 2010
Geriatric depression is associated with frontolimbic functional deficits, and this frontal dysfun... more Geriatric depression is associated with frontolimbic functional deficits, and this frontal dysfunction may underlie the marked executive control deficits often seen in this population. The authors' goal was to assess the integrity of frontal cortical functioning in geriatric depression, while these individuals performed a standard cognitive control task. The N2 component of the event-related potential (ERP), an evoked response generated within the anterior cingulate cortex (ACC), is significantly enhanced when nondepressed individuals successfully inhibit a response, providing an excellent metric of frontal inhibitory function. The authors used a variant of a demanding Go/NoGo task-switching paradigm that required participants to inhibit response execution during NoGo trials by overcoming a potent response tendency established by frequent Go trials. The authors compared a cohort of depressed geriatric outpatients (N = 11) with a similarly aged group of nondepressed participants ...
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 2006
Approximately 30% of patients with chronic obstructive pulmonary disease (COPD) experience depres... more Approximately 30% of patients with chronic obstructive pulmonary disease (COPD) experience depression. Pulmonary rehabilitation for COPD focuses on physical conditioning, but includes behavioral interventions that may address depressive symptoms. This study tested the hypothesis that brief inpatient pulmonary rehabilitation is followed by improvement in both depressive symptoms and function in patients with COPD with major depression. The subjects, who were recruited from the pulmonary rehabilitation unit of the Burke Rehabilitation Hospital in White Plains, NY, who had COPD and major depression were consecutively admitted patients to a pulmonary rehabilitation unit. Symptoms of depression, disability, medical burden, the experience of support, and satisfaction with treatment were systematically ascertained on admission and before discharge. Three hundred sixty-one patients were screened and 63 met criteria for COPD and major depression. Depressive symptoms improved by discharge (z ...
Acta cardiologica, 2003
This study was performed to examine the safety of reducing the long-term doses of furosemide admi... more This study was performed to examine the safety of reducing the long-term doses of furosemide administered to patients with congestive heart failure (CHF) stabilized on a standard medical treatment. Twenty-nine patients with advanced CHF were treated with enalapril, digoxin, nitrates, and furosemide, as needed to alleviate their symptoms, and remained clinically stable for at least 3 months on those doses. Subsequently, the daily dose of furosemide was reduced to 1/3 of the previous dose, while the concomitant therapy was unchanged. All patients underwent a thorough clinical evaluation and right-heart catheterization before and 2 months after the furosemide dose reduction. After the treatment optimization the NYHA functional class decreased from 2.3 +/- 0.6 to 1.4 +/- 0.6 (p = 0.000), and the left ventricular ejection fraction increased from 22 +/- 10% to 32 +/- 13%, (p = 0.000). Clinical and haemodynamic evaluation before and after 2 months of treatment with lower furosemide doses s...
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry
The authors compared the efficacy of problem-solving therapy (PST) and supportive therapy (ST) in... more The authors compared the efficacy of problem-solving therapy (PST) and supportive therapy (ST) in a group of elderly subjects with impairment in executive functions. This group was targeted because it has been shown to be at the risk for poor response to pharmacotherapy. A total of 25 elderly subjects with major depression and abnormal scores in initiation/perseveration and response inhibition tasks were randomly assigned to receive weekly sessions of PST or ST for 12 weeks. The subjects were systematically evaluated by raters blind to the study hypotheses. PST was more effective than ST in leading to remission of depression, fewer post-treatment depressive symptoms, and less disability. A substantial part of the change in depression and disability was explained by the subjects' improvement of skills in generating alternatives and in decision-making. This preliminary study suggests that PST is effective in reducing depressive symptoms and disability in elderly patients with majo...
The American Journal of Geriatric Psychiatry, 2015
To test the hypotheses that (1) clinical case management integrated with problem-solving therapy ... more To test the hypotheses that (1) clinical case management integrated with problem-solving therapy (CM-PST) is more effective than clinical case management alone (CM) in reducing depressive symptoms of depressed, disabled, impoverished patients and that (2) development of problem-solving skills mediates improvement of depression. This randomized clinical trial with a parallel design allocated participants to CM or CM-PST at 1:1 ratio. Raters were blind to patients' assignments. Two hundred seventy-one individuals were screened and 171 were randomized to 12 weekly sessions of either CM or CM-PST. Participants were at least 60 years old with major depression measured with the 24-item Hamilton Depression Rating Scale (HAM-D), had at least one disability, were eligible for home-based meals services, and had income no more than 30% of their counties' median. CM and CM-PST led to similar declines in HAM-D over 12 weeks (t = 0.37, df = 547, p = 0.71); CM was noninferior to CM-PST. The entire study group (CM plus CM-PST) had a 9.6-point decline in HAM-D (t = 18.7, df = 547, p <0.0001). The response (42.5% versus 33.3%) and remission (37.9% versus 31.0%) rates were similar (χ(2) = 1.5, df = 1, p = 0.22 and χ(2) = 0.9, df = 1, p = 0.34, respectively). Development of problem-solving skills did not mediate treatment outcomes. There was no significant increase in depression between the end of interventions and 12 weeks later (0.7 HAM-D point increase) (t = 1.36, df = 719, p = 0.17). Organizations offering CM are available across the nation. With training in CM, their social workers can serve the many depressed, disabled, low-income patients, most of whom have poor response to antidepressants even when combined with psychotherapy.
The American Journal of Geriatric Psychiatry, 2014
We developed a personalized intervention for depressed patients with COPD (PID-C) aimed to mobili... more We developed a personalized intervention for depressed patients with COPD (PID-C) aimed to mobilize patients to participate in the care of both conditions. We showed that PID-C reduced depressive symptoms and dyspnea-related disability more than usual care over 28 weeks. This study focused on untangling key therapeutic ingredients of PID-C. Randomized controlled trial. Community. 138 patients who received the diagnoses of COPD and major depression after screening 898 consecutive admissions for acute inpatient pulmonary rehabilitation. Nine sessions of PID-C compared with usual care over 28 weeks. Primary outcome measures were the 17-item Hamilton Depression Rating Scale and the Pulmonary Functional Status and Dyspnea Questionnaire-Modified. Other measures were adherence to rehabilitation exercise (≥2 hours per week) and adherence to adequate antidepressant prescriptions. Low severity of dyspnea-related disability and adherence to antidepressants predicted subsequent improvement of depression. Exercise and low depression severity predicted improvement of dyspnea-related disability. PID-C led to an interacting spiral of improvement in both depression and disability in a gravely medically ill population with a 17% mortality rate over 28 weeks and an expected deterioration in disability. The interrelationship of the course of depression and dyspnea-related disability underscores the need to target adherence to both antidepressants and chronic obstructive pulmonary disease rehabilitation. PID-C may serve as a care management model for depressed persons suffering from medical illnesses with a deteriorating course.
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry
The authors evaluated the impact of an increase in depressive symptoms at 6 months after elective... more The authors evaluated the impact of an increase in depressive symptoms at 6 months after elective coronary artery bypass graft surgery on long-term cardiac morbidity and mortality between 6 and 36 months postoperatively. Patients who had low scores for depressive symptomatology pre-operatively and who completed follow-up at 6 months were contacted again 36 months after surgery to assess cardiac and neurologic morbidity and mortality. At 36 months after surgery, an interval history was completed, and baseline questionnaires were readministered. Follow-up was obtained on 123/124 patients (99%). The rate of combined new cardiac morbidity/mortality between 6 and 36 months was 13.6% among those with newly increased depressive symptoms at 6 months vs. 3.0% in the patients without new depressive symptoms at 6 months. Only an increase in depressive symptoms at 6 months was related to the occurrence of subsequent cardiac complications between 6 and 36 months. In this small sample of patients...
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry
It has been proposed that a "depression-executive dysfunction (DED) syndrome" occurs in... more It has been proposed that a "depression-executive dysfunction (DED) syndrome" occurs in late life. This assertion was based on clinical, neuropathological, and neuroimaging findings suggesting that frontostriatal dysfunctions contribute to the development of both depression and executive dysfunction and influence the course of depression. The authors describe the clinical presentation of DED and its relationship to disability, studying 126 elderly subjects with major depression and evaluating depressive symptoms, cognitive functioning, disability, and personality dimensions. Patients with the DED syndrome had reduced fluency, impaired visual naming, paranoia, loss of interest in activities, and psychomotor retardation, but showed a rather mild vegetative syndrome. Depressive symptomatology, and especially psychomotor retardation and loss of interest in activities, contributed to disability in DED patients, whereas paranoia was associated with disability independently of ex...
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 2001
The authors analyzed the relationship between a provider's diagnosis of depression and health... more The authors analyzed the relationship between a provider's diagnosis of depression and health services utilization among all elderly patients (N=3,481) seen in a primary care practice over 12 months. Of patients with a diagnosis of depression, 29.7% were given an antidepressant. Depressed patients had increased outpatient resource utilization, including frequency of appointments, number of laboratory tests, X-rays and scans, and consultations. This association remained significant after controlling for comorbidity. On average, patients who were depressed had two more appointments per year. No difference in total cost of hospitalization was observed between the two groups. This study also demonstrated a higher incidence of nonspecific medical complaints in depressed vs. non-depressed elderly primary care patients, and all such nonspecific symptoms were associated with increased total ambulatory costs, tests and consultations. The somatic presentation of depression may contribute ...
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 2000
The authors asked whether impaired executive functioning and long P300 latency are related dysfun... more The authors asked whether impaired executive functioning and long P300 latency are related dysfunctions and whether they are associated with geriatric depression. A group of 25 elderly depressed patients without dementia and 20 control subjects were assessed on tasks of fluency, initiation and perseveration, the Stroop task, the Wisconsin Card Sorting Test (WCST) perseverative error score, and P300 latency. The groups' performance differed significantly on these tasks and in P300 latency. Longer latency was associated with poorer performance in both groups on all measures except WCST perseverative errors. Regardless of patients' depression status, increased P300 latency predicts poorer performance on executive function tasks requiring speeded performance.
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Papers by George Alexopoulos